A Good Death Palliative Care

A Good Death A Reflection on Ombudsman Complaints about End of Life Care in Irish Hospitals
A Good
Death
A Reflection on Ombudsman Complaints
about End of Life Care in Irish Hospitals
i
2014 © Office of the Ombudsman
Office of the Ombudsman
18 Lower Leeson Street, Dublin 2
Telephone: 01 - 639 5600 / LoCall: 1890 22 30 30
Email: ombudsman@ombudsman.gov.ie
Website: www.ombudsman.ie
Twitter: @officeombudsman
Contents
Introduction 3
How can the Ombudsman contribute

to the debate on End of Life Care? 4
The National Context 6
Complaints included in this review 7

Communications 8
Patient Autonomy 12
Specialist Palliative Care 16
Support for Families and Friends 20
Post-Mortem Examination 26
Returning the Deceased Person’s Belongings 30
Managing Complaints 32
Conclusions 34
1
“Because of the support he
received, my husband died
well. Because my husband
died well, I live well”
(Forum on End of Life, Dublin Castle, October 2013)
Good Death
Introduction
Death is something we will all experience, when our loved ones die, and
when we come to the end of our own lives. Some people live with life limiting
conditions for some time; others die suddenly or with little warning.
As individuals we want our experience of dying to be peaceful and dignified. As family members and
friends, we want to know that our loved ones were pain-free and comfortable and that we can grieve
in privacy at the time of death, and with the supports we need afterwards.
Talking about death is not easy. It is clear however that as individuals and society we need to have a
frank and honest conversation about it. We need to create for ourselves the best chance of having a
good death and allowing those who remain behind to experience a healthy grieving process.
Many public bodies and voluntary groups have responsibility and interest in this area. These include
the Health Service Executive, the Health Information and Quality Authority, the Irish Hospice
Foundation, the Forum on End of Life and the many organisations representing professional and
patient interests.
The Irish Hospice Foundation and the Forum on End of Life are working to promote openness about
the issues of where we die, how we die and how we should plan for it. They have highlighted the
need to talk, plan and act in order to ensure a dignified death for as many people as possible and a
peaceful life for those who are bereaved.
Our legislators recognise this. The Oireachtas Committee on Health and Children spent a significant
period of time in October and November 2013 listening to the views of experts and interest groups
on the challenges posed by this ‘ taboo’ subject, so that they could familiarise themselves with the
problems and possible solutions.
The Ombudsman too can play a role in the national debate and exploration about death. Despite
the personal trauma involved, the experiences of most patients and their relations in care settings
reflect a service which is caring, professional and dignified. However, over the years, the Office
continues to receive many complaints relating to end of life events. The numbers may be low, but
the experiences are unique and in many instances, had a profoundly disturbing effect on family
members. We decided to reflect on some of the complaints we received in recent years and to draw
from them common themes that may assist service providers and policy makers to improve practice.
Some of the stories shared here are sad and reflect the intense emotion of those directly involved.
However in order to improve the experiences of people in the future we need to tell their stories and
learn from our mistakes.
We hope these reflections will make a positive contribution to the national debate on end of life care
and the campaign to make Ireland a good place to live in and to die in.
If there is one message to be learned from complaints brought to us, it is that small things make a
big difference. Those moments at the end of a loved one’s life are extremely precious and will be re-
lived again and again. Excellent communication and a positive, respectful attitude are required from
all people associated with the care of the dying person and their loved ones. I hope that the stories
related here will remind us to keep this in mind at all times.
Peter Tyndall
Ombudsman
2014
3
How can the Ombudsman

contribute to the debate
on End of Life Care?
Role
The Ombudsman examines the administrative actions of a wide range of public
bodies. Where complainants have not been dealt with properly and fairly, the
Ombudsman suggests appropriate redress and, where appropriate, he recommends
improvements in practices and procedures in order to avoid the repetition of
mistakes or the recurrence of poor service. In 2013 the Ombudsman assisted over
11,000 people with enquiries and went on to examine over 3,200 complaints.
Health Complaints
In 2013, 17% of all complaints examined by this Office were about the HSE. Approximately 130 complaints were
about acute hospitals and long stay care settings. When we consider the high volume of interactions that the public
have with acute hospitals over the course of a year, we can see that the annual number of complaints that reach the
Ombudsman is relatively low. There are many reasons for this.
It is important to note that the Ombudsman cannot by law examine complaints about clinical judgement, that is, the
judgement of a clinician in deciding on a diagnosis or a particular course of treatment. The Ombudsman can however
look at a range of other actions that often result in poor care, for example, poor communication, breach of procedure,
or poor administrative practices.
Making a complaint
There are many ways to make a complaint about a poor health or social care service. Usually it is best to complain
at the source of the problem. Evidence shows that many people have difficulty knowing what to do when they are
unhappy with a service and are often anxious about making a complaint. As a result, an on-line resource has been
developed to assist members of the public with the process. www.healthcomplaints.ie is an online information portal
which provides information on how to make a complaint, the range of bodies that handle health complaints and
provides sample letters and case studies to assist with the process. The site and related resources were developed by a
group of 17 agencies, chaired by the Ombudsman’s office.
Complaints provide valuable information to service providers about aspects of their service that is poor or indeed
unacceptable. Complaints about end of life care are often the most urgent and compelling.
4
“The family would like to know the steps

taken by the hospital to ensure that all these
shortcomings do not happen to someone else
as they could easily have been avoided.”
Quote from a complainant to the Ombudsman
“We have only one chance to get this right”

[Sharon Foley CEO of the Irish Hospice Foundation speaking to the Oireachtas Committee on Health and Children]
If something goes wrong with the care provided at the end of life, nothing can be done to put matters right for the
person most affected. The impact on the bereaved can be traumatic and lasting. Complainants are regularly passionate
and determined to ensure that the wrong is recognised and lessons are learned to prevent any other person or family
experiencing the problem again.
Purpose of these reflections

The purpose of this publication is not to point the finger or lay blame on particular institutions or professions. This is
purely a reflective and learning exercise. For that reason the anonymity of settings and of individuals has been preserved.
5
The National Context
Dying in Ireland
Each year 29,000 people die in Ireland and as many as 290,000 people are left
bereaved. Research carried out for the Irish Hospice Foundation (IHF) has found
that most people, 67%, would prefer to die at home. In reality only 26% will die
at home, 43% will die in an acute hospital, 25% in a long stay setting and 6% in a
hospice. The IHF research has also found that where appropriate support can be
provided, the number dying at home rises significantly.
Standards of Care
Given the diversity of settings where people die, it is not surprising that the approach to end of life care may vary
depending on the setting and the business of that setting. The Health Information and Quality Authority (HIQA) has
statutory responsibility for the development of standards in health and social care and for monitoring healthcare quality
generally. The Authority has developed the National Standards for Safer, Better Healthcare in advance of the introduction
of a mandatory licensing system for public and private health care providers. The standards, which include provision for
end of life care, have been endorsed by government.
HIQA has already developed the National Quality Standards for Residential Care Settings for Older People and the
National Quality Standards for Residential Care Settings for People with Disabilities. Both of these standards address the
provision of end of life care.
The Irish Hospice Foundation (IHF) is a national charity dedicated to improving the quality of care available to people in
life limiting circumstances and to the bereaved. The IHF is working to bring hospice care to hospital settings through the
Hospice Friendly Hospitals Programme.
Hospice philosophy
“Our Vision is that no one should face death or bereavement without the care and support they
need; Our Mission is to achieve dignity, comfort and choice for all people facing the end of life”
The Forum on End of Life in Ireland

Initiated by the IHF in 2009, the Forum’s objectives were to promote a national conversation about dying, death and
bereavement and to establish what issues matter most to people regarding end of life from a wide range of perspectives:
social, health, economic, legislative, administrative, educational, cultural and religious. The work of the Forum was driven
by the principles and values of hospice and palliative care.
6
Complaints included
in this review
The current objectives of the Forum include the development of recommendations for a national strategy to manage
end of life issues in a comprehensive way; the promotion of public engagement and a debate on end of life issues in their
broadest sense; the promotion of advance planning and the proposal that advance paramedics and senior nurses be
authorised to pronounce death.
This review tells some of the many stories that people bring to the Ombudsman.
All of the people in these stories have had highly regrettable experiences in public
hospitals at the time of a final illness and death of a loved one. All of these people
believe that they and their loved ones suffered great distress that could have been
avoided. Their experiences are being retold to show how things can go wrong and to
show how we can learn from past mistakes.
Most complaints made to the Ombudsman are multifaceted; a person may complain about communications, record
keeping, pain control, nutrition, privacy, decision making and a wide range of concerns that arise when providing care
at end of life.
This review groups complaints under recurring themes that present to the Office of the Ombudsman. These also
broadly mirror the themes identified by the Hospice Friendly Hospitals Programme, such as patient concerns, staffing
issues, organisational issues and support to families. Some complaints may appear under more than one heading. In
certain cases the review concentrates on one aspect only of a complaint.
7
Communications
Misunderstanding
about husband’s cancer
Communicating Diagnosis
Mr Clarke was a 64 year old man who was receiving treatment in hospital for lung cancer. After his death, Mrs Clarke
complained about her late husband’s care in hospital, including the way in which news of his condition was given to
her. Mrs Clarke said that following chemotherapy, she was told, that her husband’s cancer was ‘gone’.
The Consultant stated that while he would have said that he was pleased with the patient’s response to chemotherapy,
it would never have been his practice to say that a specific cancer was gone or resolved in the way that Mrs Clarke
understood.
A case like this shows how easy it is in conversation for two people to have a very different understanding of a
message. It shows how important it is for medical and nursing staff to check with patients and families that they have
a clear understanding of the information being conveyed.
8
Family room in Nenagh Hospital Pic: Kieran Clancy
Critical information withheld

from patient and family
Giving a Prognosis
Mrs Sullivan was being treated for lung cancer in hospital and underwent a number of diagnostic procedures and
treatments. When she died, her family complained that they were not told about their mother’s prognosis until she
was unconscious.
Mrs Sullivan’s daughter said that because she did not understand how ill her mother was, she had concentrated on
encouraging her to eat and become stronger. In retrospect she and her sisters wished they had known that their
mother’s condition was terminal. If they had known just how ill she was, they believe that the family could have lived
the final weeks with their mother in a different way and come to terms with her death more easily.
“As a family we should have been given the truth that would have allowed us in the last
few weeks of her life to support and assist her in coming to terms with her prognosis.
Instead we were trying to get her to eat, make her stronger and giving her hope.”
The Consultant in this case said that it was his practice to provide information about a patient’s prognosis when it
was requested and not as a matter of course. As far as he could remember, the patient in this case never looked for
information about the probable course of her illness in spite of opportunities that might have prompted this.
“We need to help staff overcome their own fears about dying and end of life, overcome the
‘tyranny of the positive’ and inappropriate reassurance in place of real conversation.”
( Bryan Nolan, Communication Coordinator, IHF, to the Oireachtas Hearings)
Staff in hospitals must first and foremost respect the rights of their patients to choose how to share their diagnosis
and prognosis with others. They must also be alert to how this has been done and be sensitive to the needs of both
patients and their loved ones. Where appropriate, staff should offer support and reassurance.
9
Lack of understanding of DNR

(Do Not Resuscitate) decisions
Explaining a DNR
What is meant by a ‘Do Not Resuscitate’ order or notice? The Ombudsman has received many complaints in this area
and it is clear that patients and families are often confused about what it means. People are also unsure about who has
the right to decide on this course of action / inaction for the patient.
Mrs Doyle was an older woman living in a nursing home when she became ill and was transferred to hospital. Her
condition deteriorated and she died several days later. When she died her son complained about the treatment
provided to his mother in her final days and he looked for her medical records.
He was clear that he and his family had agreed to a ‘Do Not Resuscitate’ notice on his mother’s file. However, he
insisted that phrases on her medical file such as ‘for comfort measures only’ and ‘for peaceful measures only’ were
never explained to him.
He believed in hindsight that by agreeing to the DNR he had also agreed to the withdrawal of medication. This upset
him greatly as he felt that this had hastened his mother’s death. He was of the view that he had the right to request
that certain treatments be made available to his mother. He was not aware of any duty on the part of the doctor to
make clinical decisions in the patient’s best interest.
The Ombudsman found that the experience highlighted the need for a more rigorous or formal procedure for making,
recording and communicating about a DNR decision. Patients and their families or next of kin, need to understand
what such a decision entails and who holds responsibility. There is a need to ensure that families or next of kin are
consulted in a clear and unambiguous way about the treatment that is likely to be provided or ceased, where the
decision has been made to adopt a DNR status. Next of kin should be able to talk to a doctor and be given information
which explains the implications of the decision for care and treatment. Nationally agreed policy should inform each
hospital’s policy and clarify the duty of the medical team in the decision making process.
10
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GoodDeath
Death A Reflection on Ombudsman Complaints about End of Life Care in Irish Hospitals
What can we learn?

Poor communication is a feature of almost every complaint sent to the
Ombudsman. There is often a gap between the message professionals intended to
give and what the relatives and friends understood. Sometimes the language used
is overly technical or complicated. Sometimes the manner in which information
is given distorts its true meaning. Sometimes the message is rushed and basic
information is omitted. More often it is the case that the information is so
overwhelming that it needs repeating and summarising, and it requires time at the
end for discussion to ensure it has been properly understood.
Patients and families often do not understand terminology that is routine to staff. Sometimes a professional’s effort
to be kind and sensitive results in vagueness and confusion. Families sometimes have the experience of clinicians
communicating with them in ways that seem defensive, arrogant, uncaring or aloof.
Cultural diversity and language differences may also give rise to difficulties for staff, patients and relatives. While
respecting cultural difference, the patient and the loved ones remain at the heart of care. Every effort must be made
to ensure that information is communicated in a clear and respectful manner to them. Medical staff need to carefully
document discussions they have with patients and relatives about diagnosis and prognosis.
There can sometimes be confusion about the rights of next of kin. This happens particularly in relation to “Do
Not Resuscitate” orders or “Comfort Only” measures orders either placed on a patient’s record, or conveyed by a
consultant to a team, without communicating this to the family. The bedside of a dying loved one is no place to engage
in conflict about these matters.
11
Patient Autonomy
Daughter not told of father’s

deteriorating condition, at his
request
A Patient’s wishes
Mr Mooney, an older man, was receiving treatment for a range of chronic conditions in an acute hospital. His
condition became more serious overnight and the staff on duty wished to contact the family. However, when the staff
suggested this to him he said that his daughter should not be contacted as she was not well herself and he did not
want to worry her. As Mr Mooney’s condition had improved somewhat and the staff knew that his daughter was due
to visit, they decided to respect his wishes.
Unfortunately, no member of staff spoke with Ms Mooney before she reached her father’s bedside and his worsened
condition was a great shock to her. Ms Mooney believed that she should have been informed of the deterioration
before meeting him.
The Ombudsman found that the hospital had respected the patient’s wishes and had documented them clearly. But
the case highlighted the need for good communication and for staff to be vigilant and empathetic to family members’
anxieties and concerns. While staff may have been too busy to notice the daughter arriving into the ward, a few kind
words with her at some point during her visit could have resolved the matter locally and prevented weeks and months
of distress as the complaint escalated eventually to the Ombudsman.
12
Patient told of terminal illness

without offering to have family
member or support staff present
A Family’s wishes versus the Patient’s wishes

Mrs Wilson was 87 years of age and a patient in an acute hospital. Her doctor told her that her illness was terminal.
Mrs Wilson’s daughter was extremely upset about this and said that she had made it clear in advance that her mother
was not to be told about her condition.
The daughter claimed that the hospital had breached its own guidelines on breaking bad news by not having a family
member or staff member present when the news was given to her mother. Ms Wilson said that the experience had
distressed her mother deeply and made her last weeks miserable.
Ms Wilson had initially found out about her mother’s condition when talking to a hospital Registrar. She said that she
told the Registrar at that point that her mother was not to be told how ill she was. She could not identify the person
with whom she had spoken and there was no record in the patient’s notes documenting the discussion.
When questioned by the Ombudsman’s office, the Consultant said that his patient had full capacity. He was unaware
that Ms Wilson had strong views about the news to be given to her mother as this was not documented. He had
exercised his clinical judgement in discussing her condition with his patient first, while offering to have a family
meeting following that. There was no record to indicate if the patient had been asked if she wished to have someone
present with her when news of her condition was broken to her.
The hospital’s guidelines on breaking bad news outlined a number of rights including the following:
yy Patients have a right to receive or not receive bad news;
yy Patients have a right to decide how much information they feel they need;
yy Patients have a right to decide who should be present during the consultation (i.e. family members including
children and /or significant others).
The guidelines also recommend that other members of the multi-disciplinary team, such as a nurse, social worker
or a pastoral care team member, should be present when the news is being communicated and during ongoing
consultations.
13
Situations like this are not “win win” for anyone. Respecting the patient’s rights must be, first and foremost, the
clinician’s concern. However, it is important that clinicians break such news extremely sensitively and that they
be informed of any requests or dynamics that might inform their decision. Health care teams must communicate
very well with each other and document all key developments in the medical chart. Good guidance to staff on such
sensitive issues as breaking bad news is critical, and should be followed by all staff.
Results of scan not disclosed
Respecting the patient’s wishes

Mrs McLoughlin was receiving outpatient treatment for cancer for more than a year at an acute hospital. Her
condition worsened suddenly and she was admitted to hospital to manage her pain. She returned to her home and
died several weeks later.
Mrs McLoughlin’s son complained that his mother’s scan results were not discussed with the family in a timely
way. Because of this, there was a delay in referring his mother for specialist palliative care and her pain was not
adequately controlled for a period of 2 months. Mr McLoughlin said that his mother and the family were deeply and
unnecessarily distressed by this.
When the medical and nursing files were examined, it emerged that Mrs McLoughlin held a very strong view that her
medical condition was private to her. It was documented that she did not wish to have this discussed with her family
without her knowledge. Furthermore, she had told her Consultant that she did not want to have a discussion about
her scan results until a family event, due to take place shortly, was over. As that event was postponed, so too was the
discussion of the scan results, but this was as Mrs McLoughlin had chosen.
The Consultant believed that if he were to refer his patient to specialist palliative care in advance of discussing the
results, this would mean in effect that he was letting her know the results. He believed that to do this would have
been in breach of his ethical obligation to abide by his patient’s wishes not to be told of the results until the date of
her choosing. The downside of this was that the specialist palliative care team was not involved in her care and her
pain control was not as it should have been.
When Mrs McLoughlin’s condition worsened before the agreed date for discussion of the scan, she was admitted to
hospital for pain control and agreed to accept home care management. She was nursed at home by her family with the
support of the team. However, the family contended that her final weeks were haunted by fear of pain and believed
that this experience could have been avoided.
14
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What can we learn?

Patient autonomy means that the patient is at the centre of decisions about his or
her care. This includes communication of information about his or her condition
as appropriate. The purpose is to respect patients’ wishes. Where their wishes are
not known, the health care team must endeavour to communicate effectively with
next of kin to ensure that the correct decision is made in the patient’s best interest.
Sometimes the rights of patients and the wishes of families are in conflict and it
can be a struggle to balance these. However, to avoid long term distress, it is best
to try and settle these conflicts as early as possible through open and sensitive
communication.
“Every patient has the right to be fully informed about their health status, including the
medical facts about their condition …. Information should be withheld from patients only
exceptionally, when there is good reason to believe that this information would, without
any expectation of obvious positive effects, cause them serious harm.”
(Ombudsman’s Statement of Good Practice for the Public Health Service in Dealing with Patients)
Patients with capacity will be informed directly of their condition by a doctor unless there is good reason not to do
this. Patients who wish to follow a different path need to have their wishes documented.
Families are sometimes unaware of where or how they can fit into the care of a loved one. They sometimes believe,
mistakenly, that they have a right to full information about their loved one as well as the right to make decisions
on behalf of the person who is ill. Staff should ensure that a patient’s wishes regarding disclosure of a condition are
documented. Staff also need to be clear about the rights of families and friends to information, particularly where the
condition of the patient may be deteriorating. Where conflict arises, open dialogue and early resolution is the better
outcome for all concerned.
15
Specialist
Palliative Care
Specialist Palliative Care Team

not contacted over a weekend
period for advice
“The Staff in the coronary care unit were so kind to us and our father and
made sure his final journey was a peaceful and dignified one.”
“Words cannot express how grateful we are to her for the care she gave to our
father.”
[A remark about a care attendant]
“I nursed my mother at home for 14 days with the support of the palliative
care team. Throughout those two weeks the fear and worry my mother
expressed was due to pain.”
“All I wanted was for people to listen so my mother would get the quality of
care that she rightly deserved.”
16
Keeping in touch with the

Specialist Palliative Care Team
“My mum was in agony on the Friday until the Tuesday. She never, to the best of my
knowledge, received any palliative care over that weekend. That angers me greatly.”
Mrs Brady was receiving treatment for cancer in hospital. Her son complained about her treatment over a particular
weekend shortly before her death. He said that the hospital had failed to manage her symptoms adequately. He believed
that his mother had been in great distress and pain over the weekend. He complained that the hospital had not called in
the on-call Specialist Palliative Care Service at this time to provide the appropriate care and relieve her pain.
The hospital explained that his mother was constantly monitored by nursing staff and was reviewed by medical staff
during the time in question. The woman was receiving a combination of pain relieving medication as advised for her
by the Specialist Palliative Care Team. Additional medication was also administered to deal with the agitation and
confusion she suffered as a consequence of her illness. The hospital said that when she did complain specifically of
pain, additional pain relief was provided.
As the decision to maintain a certain medication regime was a clinical one, the Ombudsman could not investigate
this or come to any conclusion about whether or not this was appropriate. However, the hospital conceded that, in
hindsight, it would have been advisable to have contacted the Specialist Palliative Care Team over the weekend. This
would have had the benefit of assuring the hospital staff and the family that the appropriate care was being provided
and that all alternative measures to alleviate her distress had been considered.
The hospital said that it had learned from this experience and that staff will bring the learning to bear on their decision
making in similar cases in the future and contact the on-call Palliative Care Team for guidance, at weekends.
“Pain relief depends on the knowledge, skills and attitudes of staff. Remember – the pain is
the patient’s pain”
Prof. Patrick Plunkett to Oireachtas Committee on Health and Children.
17
Preparing for a hospital

discharge and problems accessing
morphine for a patient at home
Home support
Mrs Whelan was an 85 year old woman who had a number of serious conditions including cardiac problems and
cancer. She was discharged to her home from an acute hospital and was cared for by her daughters until she died six
days later.
Her daughter complained that although her mother was seriously ill, the Public Health Nurse did not come to visit her
following her discharge from hospital until the day before she died. The family also complained that the hospital had
failed to ensure that medication for pain relief was provided.
The hospital admitted that although a referral to the Public Health Nurse was recorded, she had not in fact been
contacted by the hospital and was unaware of the patient’s needs. The actual referral was not made until a date
following the patient’s death. The visit that took place only happened because of local contacts made with the nurse.
The hospital apologised to the family for the delay and associated distress that this caused.
When their mother was discharged for the last time before her death, the family received a prescription that
afternoon which included morphine. The family received no advice on how to administer it and had to ask the
pharmacist about it. They had been promised by a member of the medical staff that they would receive a two day
supply of medication to tide them over, but this was subsequently refused by the staff on the ward who told them it
wasn’t hospital policy. In the event, the pharmacy did not have morphine in stock and the patient and family had to
wait until the next day for it. That night the family had to call out a doctor to administer an injection to their mother
for severe pain. The family felt that the hospital could have issued the prescription earlier in the day to allow them to
source the medication in a timely way, or, that it should have made contact with the pharmacy in advance to ensure
that it had a stock of morphine available.
The hospital had told the family when they made their complaint that it was not policy to contact pharmacies to
ensure that morphine was in stock and said that the pharmacy should have been able to source the morphine from
another source.
18
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What can we learn?

The quality rather than the length of life is more important to most people with a
life-limiting condition. Research by the Irish Hospice Foundation confirms this. The
patient’s priority is that pain will be managed and that he or she will be pain free.
Unfortunately it may not be possible to meet that expectation in every circumstance. Cases put to the Ombudsman
show that a peaceful, comfortable death helps both patient and relatives. In contrast, the experience of real or
apparent discomfort suffered by a patient can haunt the relatives and prolong the grieving process for them.
It is crucial for patients and families to know that they will receive palliative care if they choose it and that pain will
be controlled to the greatest extent possible. Families talking to the Ombudsman cannot understand how a patient
in a hospital might not have immediate access to effective relief. The question of what might constitute appropriate
pain relief is very much a clinical one and the Ombudsman is unable to comment on this, other than to say that the
patient’s voice should be heard.
The patient should always be at the centre of care. No one should be discharged from a hospital without arrangements
being in place to ensure that their immediate and longer term care needs, including pain control, will be met. While
every patient’s discharge must be planned extremely well, this is critically important in the case of a person who
is terminally ill. Again, these are vital moments for the patient and their family. The family, often without formal
qualifications in the delivery of care, really want to do their best for their loved one and give that person a comfortable
and dignified death. A rushed or unplanned discharge is unacceptable in those circumstances.
Patients and carers at home face a range of challenges usually of a type never faced by them before. They are
dependent on their GP, Public Health Nurse and the palliative care team where available to support and guide them
through this experience. Careful pre-planning and formal cooperation between health care professionals is required if
there is to be ‘joined up thinking’ and appropriate support for the patient and carers.
We need to avoid the situation where an already stressed carer is made to believe that it is his or her fault that their
loved one is in pain. We need to avoid situations where a traumatised family is forced to call out a doctor in the middle
of the night to administer pain relief that should have been available all along.
19
Support for Families

and Friends
Family not contacted to say

mother was dying
Timely warning
Mrs Cummins, who was 79 years old, was a patient in an acute hospital. She rang her son from the hospital one
morning and told him that she was dying. Later that evening Mrs Cummins passed away.
Her son said that when his mother rang, he immediately went to the hospital to see her. He complained that he was
not told by the hospital for a further four hours after his arrival of the seriousness of her condition. Mr Cummins said
that as a result of the hospital’s failure to speak to him directly, other members of his family who lived a distance away
did not have time to travel home to be with their mother when she died.
The hospital admitted that there had been a failure to contact the next of kin in a situation where there was clear
consent to do so and clear evidence of a deteriorating condition. As a result of the experience in this case, the hospital
put in place a written policy on contacting next of kin, to make sure that this would not happen again.
Sister told to “stop hyperventilating

– she was not helping anyone”
Breaking News of a Death

Mr O’Rourke, a young man, was seriously ill in the Intensive Care Unit of a hospital, following a head injury. Ten days
later he was transferred to a different hospital where he died.
20
Family room in Nenagh Hospital Pic: Kieran Clancy
Ms O’Rourke was recorded as the next of kin on her brother’s records and she expected that any serious
communication would be made directly to her. On the day of her brother’s death, her parents were visiting the
hospital when their son died. Unaware that her brother had just died, Ms O’Rourke arrived in the ICU and overheard
two nurses speaking of her brother’s death. She began to hyperventilate with shock and says she was told by a nurse
very abruptly to ‘stay calm as you are not helping anyone”. She was very upset to find out about her brother’s death in
this casual way and also complained that the nurses were not supportive of her when she became upset.
The hospital in question is participating in the Hospice Friendly Hospitals Programme. The hospital apologised for
what happened on this occasion and said that it hoped that participation in the HFHP would encourage a better
understanding by the staff of how to communicate sensitively with families around the time of death.
Lack of privacy when patient died
Privacy
Mr Devitt was 61 years old when he was admitted to hospital following a stroke. He was transferred to a high
dependency ward and died several days later.
Mr Devitt’s daughter made a number of complaints about her late father’s care at the end of life. The family was
especially upset because there was no single room available and hence their father died on a busy ward. When he died,
the only privacy available to the family was the curtain around his bed. The family was grieving for their father while
normal activities such as meals and television continued around them. At one point, a member of support staff had
pulled the curtain back to ask their father if he needed dinner.
The family also complained that they were asked to leave at a certain time even though the remains were left on the
ward for several hours before being moved to the mortuary. They were upset by what they saw as a lack of respect for
their father.
21
“I attended the bedside of a friend who was dying in a Dublin hospital. She lived her last
hours in a public ward with a television blaring out a football match, all but drowning
our final conversation. I have since come to believe that in hospital, aesthetics are as
important as function, and that an aesthetic environment automatically leads to good
practice and better care.”
Actor Gabriel Byrne
Treatment of the remains

after death
Dignity after death

“This was my father; he was a unique human being. After helping to save three other lives,
it seems to us he was simply put to one side and given no more thought.”
Mr Byrne was admitted to hospital following a fall. He had suffered irreversible brain injury and the medical team
discussed organ donation with the family. As their father had been an enthusiastic supporter of organ donation, the
family agreed to this. Mr Byrne was pronounced dead in accordance with the appropriate procedures.
While the care provided up to this point was unquestioned, from the time that the family agreed to the organ
harvesting procedure, things went wrong. The hospital failed to contact the Coroner in a timely way to enable an
identification to take place when Mr Byrne was pronounced dead. The family understood that the hospital would get
in touch with them as soon as the organ harvesting procedure was over, but this did not happen.
When the family themselves contacted the hospital a day later they were eventually told that the procedure was
completed and that they would now need to undertake a Garda ID of the remains. They made their way to the hospital
to do this. The family describe a lengthy walk in and out of corridors, out through an open space strewn with rubbish
and debris, until they eventually were brought by a back door into what they believed was the mortuary.
They described finding their father’s body on a slab ‘with nothing more than a sheet thrown over him’. They spoke of
the ongoing trauma of reliving this scene. Although the hospital said that the remains were gowned, the family stated
that his shoulders were bare and they believed their father to be naked. The hospital in this case acknowledged that
mistakes were made and apologised to the family for the distress caused. The hospital also recommended that the End
of Life Committee in the hospital produce an action plan to avoid a recurrence of the problems that arose.
22
Poor communication with

bereaved family
Sudden death
Mr Donohoe had a number of diagnostic procedures as an inpatient. Eventually a diagnosis of pancreatic cancer was
made. Mr Donohoe remained in hospital while palliative care options were being discussed. His condition deteriorated
suddenly one night and he died an hour later.
Mr Donohoe’s daughter had several complaints about her late father’s end of life care, including the way in which news
of his terminal condition was eventually communicated to him, his hygiene and grooming care, and the management of
his pain. She said that the most distressing issue for the family was the failure to alert them when Mr Donohoe became
seriously ill. By the time the hospital contacted the family, Mr Donohoe had already died.
Mr Donohoe’s daughter said that when her family arrived at the hospital they were brought to view their father’s
remains in a public ward. This was during the night. The family became upset and were asked to leave as they were
disturbing other patients. They said that no one sympathised with them or offered to explain what had happened to
their father.
Family had to ask for Last Rites
Respect for religious beliefs

Mr Brennan was being treated for cancer. He had been ill for some time and his condition was terminal, but when his
death occurred it was unexpected.
Mrs Brennan made a number of complaints about her husband’s end of life care. One of the issues raised was that
there was a delay in arranging to have the priest called to administer the Last Rites. She herself had to request that
this be done. The priest was eventually called, but it was an hour before he could attend and the family was very upset
by the delay.
23
The hospital agreed that the complaint highlighted weaknesses within the hospital in relation to the quality of
standards around end of life care. The hospital accepted that, although staffs were aware of the protocol, there was
delay in contacting the priest as they were busy at the time attending to the needs of other sick patients.
The hospital apologised to the family for the distress caused and told the Ombudsman that it was working in
conjunction with the Hospice Friendly Hospitals Programme to make good end of life care central to the work of the
hospital. Since dealing with this complaint, the hospital has provided leaflets to bereaved families, providing useful
information and contact details.
Educating the Carer
Ensuring that the Carer knows what to expect

“I didn’t know what questions to ask – I only found out what I needed to ask as I went
through the experience of caring for my mother.”
Mrs Brown had pancreatic cancer. Following reviews by the Specialist Palliative Care Team Mrs Brown was discharged
home into her daughter’s care. Mrs Brown was reluctant to consider the involvement of the Hospice at that point and
it was her wish to die at home when the time came.
On the day of her death, Mrs Brown became unwell and experienced some breathing difficulties. Her daughter was
unsure whether her mother needed to be readmitted to hospital and she sought assistance from her GP. However,
the GP only managed to call out to her home later that evening which meant that Mrs Brown was without medical
assistance throughout the afternoon.
The GP diagnosed septicaemia but advised against moving Mrs Brown to hospital. The emergency services attended
Mrs Brown and provided oxygen to relieve her breathing distress. However, the emergency services could not provide
the drip treatment which she would have needed to help treat her condition. The hospice nurse attended shortly
afterwards and Mrs Brown later died as she had wished, in her own home.
After her death, Mrs Brown’s daughter made the point that carers should be properly briefed so that they are as well
equipped as possible to meet the needs of the dying patient. Her daughter said that it would have been beneficial for
her had a formal “hand over meeting” taken place, attended by both the oncology team and the palliative care team,
so that all relevant information could have been provided to her.
She said that this should be standard practice in hospitals. “It takes many years for doctors and nurses to qualify - it
is only fair therefore that the carer(s) would be offered this opportunity before they are required to manage the final
stage of terminal illness and the death of the person they love”.
24
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She told the Ombudsman that she simply did not know what questions to ask at the time and only realised what she
needed to know as she went through the experience of caring for her dying mother. She considered that had some
printed information and advice been available to her with regard to what she could expect, this would have been most
useful. While such information is available to staff, there is no literature currently available to carers or relatives who
are looking after terminally ill patients at home.
What can we learn?

Families have certain needs when dealing with the end of life care and death of
their loved one. Every death is unique and for families, every death, even when it is
expected, is deeply emotional. In some cases it may be the family’s first experience
of death and they may be completely unsure of what to expect and what must be
done. It is natural that they will look first and foremost to the setting where the
person has died for advice and guidance. They will expect clear information and
good, effective support from that organisation.
Good communication is at the core of these needs. For example, families need practical and comprehensive
information on what to expect and how to cope when a patient is discharged home. Families will depend on the
hospital to have alerted community services to their urgent need in the home. They will expect the experts to
forewarn them of likely difficulties and to offer advice and assistance on how these will be managed.
Families need support and compassion, regardless of whether death is expected or occurs suddenly. Families will differ
in their response to the death of a loved one. Some family members will need to leave the scene and seek space on
their own for a time; others will want to spend time with the remains. In many unfortunate instances, death occurs
suddenly before a family can reach the bedside of the dying person and the immediate reality of the death strikes
home only when they see the remains. This has to be expected and the proper facilities should be available.
Whatever the circumstances of a death, it is the experience of the Ombudsman that where and how the family spend
their final moments with their loved one, before and after death, is very significant. A traumatic experience can have
significant consequences for the grieving process. The opportunity for next of kin to view, or spend time with, their
loved one after death is precious. In ideal circumstances this will take place in a dedicated private space, sensitively
decorated and appropriately lit and the family will have as much time as they need. The family will have been told in
advance what to expect in terms of the condition of the dying person or the remains to minimise any shock.
All hospitals should have clear internal communications procedures for communicating with patients and families.
The hospital system, as distinct from individual departments or sections, should ensure that all foreseeable instances
are planned for and staff know what they should do. When a death has occurred, staff should sensitively extend their
condolences to all relevant family members and friends.
25
Post-Mortem
Examination
No information about the

family’s right to ask for a
post-mortem examination
Explaining Options for a Post-Mortem

Mr Brennan had been ill for some time when his cardiac function deteriorated rapidly and he died suddenly in
hospital. Mr Brennan’s wife wanted to find out exactly what the cause of death was, because her husband had died
unexpectedly. She was upset that no post-mortem was carried out to establish this.
The hospital explained that the man’s death did not fit the criteria for a Coroners’ post-mortem but apologised to the
woman for the fact that the option of a hospital post-mortem had not been discussed with the family at the time. The
medical team could have decided to do a post-mortem themselves, even if the Coroner did not require one, but they
had not considered this necessary and were not aware that the family would have valued the information it might
have given.
As a result of the woman’s complaint, the hospital undertook to review and amend its guidelines following the death
of a patient to include discussion with the family about a post-mortem where relevant.
26
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Refurbished Mortuary, Mercy Hospital Cork Pic: GMC Photography
Hospital did not perform

post-mortem following
patient’s fall
Providing explanations
Mr Devitt was receiving treatment in hospital following a stroke. He had at least one fall while a patient, this being
quite a severe one where he broke a tooth and suffered a serious laceration to his head. His family were very shocked
by his death a couple of days after this fall. His daughter complained that the hospital had delayed in informing the
Coroner of her father’s death and had not carried out a post-mortem. As a result, the family did not know whether
their father had died of the admitting cause, a stroke, or as a result of the fall and injury to his head.
Following the Ombudsman’s intervention the hospital apologised unreservedly to the family for the distress caused
and undertook a range of initiatives to prevent this happening again.
Failure to arrange
post-mortem examination
Timely arrangements
Mrs Fleming was 82 years old and living in a residential care setting for older people. Mrs Fleming suffered from
Alzheimer’s disease and had been assessed as being at high risk of falls. She died eighteen months after going to live
in the facility.
27
Mrs Fleming’s family had a number of complaints about their mother’s care and death. One of the complaints
concerned the family’s wish to donate their mother’s brain to a neurological research facility at a local hospital, an
idea that had been proposed to them by one of the medical staff caring for their mother, and how this wish was
frustrated. The family also requested a post-mortem to determine the cause of death as their mother had a number
of traumatic falls in the days preceding her death. The family believed the post-mortem had been agreed to by the
medical consultant.
The family assumed that their mother’s body would be transferred to the hospital on the day that she died and that
the post-mortem and donation of tissue would take place the following day. Instead they discovered that her body had
remained in the nursing home mortuary and that no arrangements had been made for the post-mortem. The family
was greatly distressed by the situation. Ultimately, after much delay and confusion, they decided to withdraw the
request for a post-mortem and the offer to donate their mother’s brain for research.
The Ombudsman investigation found that the absence of appropriate protocols between the facility and the hospital
delayed the transfer of the body to the hospital. The investigation found that there had been a complete breakdown in
communication between staff in the nursing home, staff in the hospital and the family.
Family could not view loved one

in public mortuary
Death in a Public Place

Mr Fitzgerald was hill walking when he became ill suddenly and died. The Ambulance service and the Gardai attended
at the scene. Mr Fitzgerald was unresponsive to intervention by the Ambulance crew and the crew decided that there
was no point in bringing him to the hospital. It was decided to remove his body to a local undertaker / funeral home.
From there his body was removed to a public mortuary at the request of the Gardai, as a post-mortem was required.
When the family arrived at the mortuary some time later, they were told that they could not visit Mr Fitzgerald’s
remains. They understood that this was because his death had not yet been formally certified by a doctor, but were
very distressed and clearly wanted to spend time with him.
The Coroner later explained to the Ombudsman that the family was unable to view the remains, not because of a
problem about the certification, but because the mortuary did not have the facilities or staff to enable this to take
place. He said he was sorry for the distress caused to the family and regretted that the situation was not explained to
them before they made the journey to the mortuary.
28
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What can we learn?

The Ombudsman has received many complaints over the years relating to
post-mortems. Post mortems are rarely something we give much thought to until
faced with a traumatic event. Families are often uncertain about the circumstances
in which the Coroner may require a post-mortem to be carried out. They may be
unaware that a hospital post-mortem can be carried out to determine the cause of
death, even if not required by the Coroner, and are often unaware that they may
request such a post-mortem. Complaints have also been made about delays in
arranging for post-mortems or in having the remains released or available to view.
The death of a loved one, whether anticipated or unexpected, is always traumatic for the relatives. The HSE’s
Standards and Recommended Practices for Post-Mortem Examination Services recognises how important the
post-mortem examination process is for families in providing information and comfort about the care of the loved
one. Confusion around the need for, or right to, a post-mortem, can only compound the problems of the bereaved.
Yet again, complaints like this show the need for good communication, clear procedures and adherence to procedures.
29
Returning the
Deceased Person’s
Belongings
Belongings, soiled and clean,

returned in plastic bags
Mr Prendergast was a patient for several months in hospital where he was being treated for cancer and eventually
died. After his death his partner made several complaints about his treatment and care. One of the many complaints
made by her was that her partner’s belongings (both soiled and clean) were returned to her in green plastic bags.
The soiled clothing was a stark reminder to her of his pain and suffering in his final days. The return of his personal
belongings in refuse sacks, so impersonally and insensitively, was far from the dignified approach she felt should have
been taken. She saw the hospital’s actions as careless, thoughtless and lacking in respect.
30
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Family Handover Bag
What can we learn?

Returning a deceased patient’s belongings to his or her family needs to be managed
sensitively.
What seems like a simple action can highlight the different attitudes of staff and bereaved relatives. Returning
belongings is a routine task for hospital staff. Staff are used to seeing clothing or belongings in a soiled state and of
course, they are obliged to return these to the relatives.
To the relative, the return of the belongings is evidence of the loved one’s death, and evidence that his or her death
may have taken place in unpleasant circumstances. To some people the manner in which the belongings are returned
will not matter; to others the use of a plastic bag is disrespectful and it is important that the belongings are presented
in a more appropriate way. Some people might prefer not to have soiled or damaged clothing returned to them at all
and it might to appropriate to have hospital staff offer the choice of disposing of items.
This issue was initially raised when the Ombudsman conducted a formal investigation into end of life care in one
acute hospital. As a result of the investigation, the IHF introduced the concept of the ‘Handover Bag’, designed to
return belongings in a formal and dignified way. It was disappointing to see the same problem occurring in a different
hospital.
31
Managing Complaints
Doctor responds to complaint

defensively and insensitively
“It gives me great peace of mind that my letter of complaint has and will continue to lead
to a number of changes in practice in the Radiology Department and hopefully deter such
poor standards of care occurring again.”
Poor response to complaint

Families are regularly upset by the reaction of hospitals when they complain. Ms O’Rourke wrote a letter to one of the
hospitals that had cared for her late brother, setting out her concerns about his treatment.
She received a response from the leading Consultant in which he failed to offer condolences and was critical of her
decision to complain to the hospital rather than directly to him. Ms O’Rourke found the tone of his letter defensive,
offensive and intimidating. Because she felt so intimidated and upset by the response, Ms O’Rourke could not bring
herself to meet with the Consultant and others involved in her brother’s care. This was unfortunate as it prevented
her from gaining access to information about her brother’s condition, care and death. This was information that she
needed to bring some closure to her and her family’s loss.
The Ombudsman asked that the case be brought to the attention of all Consultants in the hospital so that they would
appreciate how a certain approach to a complaint could have such a negative impact on a family, and to show how
important it is to communicate non-defensively and sensitively with families, whether verbally or in writing.
32
What can we learn?

A more consistent, timely and high quality approach is needed to deal with health
complaints. An Ombudsman review of complaints handling to identify good practice
and failings is currently underway, and will make recommendations designed to
secure improvements in the future.
Good complaints management is a key element of good administration and service delivery. Every well run
organisation recognises that things will go wrong from time to time. The way to deal with this is to have accessible,
open and prompt complaints systems that objectively identify and acknowledge where errors have occurred, that
apologize where appropriate and that continuously change systems to improve services and provide reassurance to
service users. Defensive, incomplete, superficial or delayed responses on the other hand only go to increase the sense
of anger, frustration and disappointment felt by complainants. They also fail to make the most of opportunities to
learn from poor service delivery and to stop such failures recurring.
The recent establishment of hospital groups provides an opportunity for better resourced complaint handling and to
share learning from individual complaints.
33
Conclusions
The complaints set out in this review provide a glimpse into end of life experiences
in acute hospitals and show the range of difficulties that can arise. The experience of
the Ombudsman is that many problems arise because of poor communication and
oversights often caused by resource deficits.
Communication
Almost every case in this review, and most of those that come to the Ombudsman, arise because of poor
communication at some level and lack of clarity about the respective duties and rights of doctors, nurses, patients and
families or friends.
Health professionals work in a busy and stressful environment. They work with people who have usually not chosen to
be in that environment and who may be very ill or distressed. Health professionals and other staff working with dying
people must make every effort to provide the space and time to communicate clearly and empathetically with patients
and their families. To the patient and his or her family, that skill is integral to the high quality medical and nursing
care expected from the hospital.
Good communication depends on more than empathetic communication between individuals. Patients and families
need to know that they can rely on an institution to deliver the best care possible. Communication systems within
hospital departments, between doctors, between nurses, with the family, with related settings and with services
outside the hospital (including General Practitioners and Public Health Nurses), need to be planned, well structured
and effective so that patients and families will have proper and timely access to the supports they expect and require.
Families and friends may not be clear about the unique relationship of a patient to a doctor and the rights of the
patient over that of the family. This will have implications for the care of a patient and can leave family and friends
in the dark as to what is happening to their loved one. Doctors and staff may on occasion be unclear themselves as to
how much information they in turn should communicate to family and friends in these circumstances. It is clear too
that patients do not always want to communicate openly with their own families and this can lead to dilemmas if the
patient’s condition deteriorates.
The language and way in which information is communicated is crucial. Information needs to be shared using simple
clear language, in a manner that treats the patient and family or friends as equals, facilitating the emergence of the
‘expert patient’ as envisaged by the Health Service Executive. When patients and relatives express their fears about
a diagnosis, a prognosis, or pain control, they need to know that staff will listen to them, take them seriously and
respond with the reassurance or action that is needed. Time is often required for good communication, and there is
rarely an over-supply of it, but professionals need to be clear on the importance of these conversations at the end of
life or after a death. Hospital staff also need to be vigilant in documenting any important actions or discussions.
34
Resources
Regularly an overburdened staff and lack of physical facilities feature in complaints. Sometimes the defence offered
by staff of being very busy and under pressure does not explain or justify the poor and insensitive service. Sometimes
Title
management has no choice but to accept the fact that services are unviable unless further investment is provided.
With regard to physical facilities, patients and families want peace and privacy at the end of life. For most people this
means access to a private room. Relatives need a private space to spend time with a loved one after death, a space clear
of normal hospital routine, where they can grieve without worrying about the needs of other patients, or without being
observed by others.
Relatives need to see their loved one cared for in a dignified way after death. For relatives this means that the remains will
be dressed or covered appropriately and can be viewed in a clean and calm place.
Pain Management
The question of when, or if, palliative care should be suggested to a patient is a matter of clinical judgment outside
the competence of the Ombudsman and is clearly something for clinicians and others to debate. What is clear to the
Ombudsman however is that patients want to be as comfortable and pain free as possible and that acute hospitals are
expected to rise to the challenge of meeting that expectation, within ethical and medical constraints, and while respecting
the wishes of individuals. The hospital has a responsibility to ensure that a patient who has been discharged has been
brought to the attention of local services in a timely manner and will have their pain control needs met at home.
The Way Forward

The Forum on End of Life in Ireland has encouraged communities to have a more open attitude to dying and death, and
to the broad range of issues that death raises. Using tools such as the citizen-led Think Ahead form, we are encouraged
to plan and to have our wishes and preferences recorded and respected. HIQA standards also make provision for such
advance care planning and consultation.
It is a matter for individuals to decide whether or not they want to plan ahead to spell out their preferences in the event of
a significant health emergency or in the face of a serious prognosis. Certainly such clarity may make life easier for health
professionals and may lead to more comfortable experiences for patients and families.
Regardless of individual advance care planning, the onus remains on all those responsible for providing health care to
ensure that the service at end of life is completely focussed on the dying person’s needs and thereafter their loved ones.
Service providers need to continuously improve and learn from mistakes that have occurred.
The Ombudsman will continue to contribute to that process by examining complaints in an independent and impartial
manner and by providing feedback to complainants and service providers. The Ombudsman commends the Irish Hospice
Foundation, the Hospice Friendly Hospitals Programme, and all other public and volutary organisations who strive to
provide excellent care for people at the end of their lives.
35
36
Refurbished Mortuary, Mercy Hospital Cork Pic: GMC Photography
2014 © Office of the Ombudsman
Office of the Ombudsman
18 Lower Leeson Street, Dublin 2
Telephone: 01 - 639 5600 / LoCall: 1890 22 30 30
Email: ombudsman@ombudsman.gov.ie
Website: www.ombudsman.ie
Twitter: @officeombudsman

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A Good Death A Reflection on Ombudsman Complaints about End of Life Care in Irish Hospitals

How can the Ombudsman contribute

The National Context 6

Complaints included in this review 7

How can the Ombudsman

“The family would like to know the steps

“We have only one chance to get this right”

Purpose of these reflections

The National Context

The Forum on End of Life in Ireland

Critical information withheld

Lack of understanding of DNR

What can we learn?

Daughter not told of father’s

Patient told of terminal illness

A Family’s wishes versus the Patient’s wishes

Results of scan not disclosed

Respecting the patient’s wishes

What can we learn?

Specialist Palliative Care Team

Keeping in touch with the

Preparing for a hospital

What can we learn?

Support for Families

Family not contacted to say

Sister told to “stop hyperventilating

Breaking News of a Death

Family room in Nenagh Hospital Pic: Kieran Clancy

Lack of privacy when patient died

Treatment of the remains

Dignity after death

Poor communication with

Family had to ask for Last Rites

Respect for religious beliefs

Educating the Carer

Ensuring that the Carer knows what to expect

What can we learn?

No information about the

Explaining Options for a Post-Mortem

Refurbished Mortuary, Mercy Hospital Cork Pic: GMC Photography

Hospital did not perform

Family could not view loved one

Death in a Public Place

What can we learn?

Belongings, soiled and clean,

Family Handover Bag

What can we learn?

Doctor responds to complaint

Poor response to complaint

What can we learn?

The Way Forward

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